Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study

Abstract

Background Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5–14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. Objective To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. Methods Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. Results Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. Conclusions Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Development and test–retest reliability of a screening tool for axial spondyloarthritis

“…In addition, the proposed screening questions were informed by our previous work in which we explored issues related to patients' diagnostic journeys using evidence-based qualitative research methodology. This helped us to understand and incorporate patient and physician perspectives [15,17,45]. Our study also has several limitations.…”

“…The primary goal of this study was to develop a patient-friendly screener that reflects patient experiences. Considering the complexity of the US healthcare system and the challenges associated with implementation of a screening tool in primary care settings [15,46], evidence to ensure its usefulness in routine primary care practice will be important. In our previous work, we demonstrated that the proposed screener possesses the necessary properties to serve as an effective screening tool: it is brief, understandable at a grade 8 reading level, and can be self-administered [17].…”

“…Studies show that primary care physicians have difficulty differentiating inflammatory back pain (IBP) from the more common mechanical back pain [13,14] or are unaware of other features of spondyloarthritis that are important for differential diagnosis [12,14]. We previously conducted qualitative research with primary care providers in which they agreed that improvements in screening and early detection of axSpA are needed [15]. The Assessment of SpondyloArthritis International Society (ASAS) Inflammatory Back Pain Assessment: ASAS Expert Criteria screening questions have been used in primary care settings to screen for axSpA [15,16].…”

“…We previously conducted qualitative research with primary care providers in which they agreed that improvements in screening and early detection of axSpA are needed [15]. The Assessment of SpondyloArthritis International Society (ASAS) Inflammatory Back Pain Assessment: ASAS Expert Criteria screening questions have been used in primary care settings to screen for axSpA [15,16]. However, primary care providers considered that some of these questions were neither sensitive nor specific and needed improvement [15,16].…”

“…The Assessment of SpondyloArthritis International Society (ASAS) Inflammatory Back Pain Assessment: ASAS Expert Criteria screening questions have been used in primary care settings to screen for axSpA [15,16]. However, primary care providers considered that some of these questions were neither sensitive nor specific and needed improvement [15,16].…”